Is Antipsychotic Reduction Making You Crazy

Is Antipsychotic Medication
Reduction Making You Crazy?
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc. (HHI)
Presented by:
Kim Steele RN, WCC, RAC-CT, CHHRP
Regional Consultant and Trainer

Speaker Bio
Regional Consultant and Trainer for Harmony Healthcare
International, Inc.
Over 28 years experience in Long-term Care and Cardiac CCU
Shift Supervisor
MDS and Care Plan Coordinator for 5 years
Director of Nursing for 18 years
Trained staff in IV-Certification, MDS 2.0, MDS 3.0, PPS, ADLs and
Regulatory Compliance, Infection Control and OSHA
Specialty in Wound Care and Survey Compliance for both Standard
and QIS Surveys
Provides education in all aspects of Therapy and Nursing Medicare
Documentation Requirements, completing CAAs and Care Plan
Development, Wound Assessment and Documentation
Expert in NY State Medicaid/CMI Reimbursement and Documentation
and training for Successfully Preparing for the NY State OMIG Audit
Copyright © 2013 All Rights Reserved 2Harmony Healthcare International, Inc.

Is Antipsychotic Medication reduction
Making You Crazy?
Disclosures: The planners and presenters of this educational
activity have no relationship with commercial entities or
conflicts of interest to disclose
Planners:
Elisa Bovee, MS, OTR/L
Diane Buckley, BSN, RN, RAC-CT
Beckie Dow, RN, RAC-MT
Keri Hart, MS CCC, SLP, RAC-CT
Kristen Mastrangelo, OTR/L, MBA, NHA
Christine Twombly, RNC, RAC-MT, LHRM
Presenter:
Kim Steele, RN, WCC, RAC-CT, CHHRP

Is Antipsychotic Medication reduction Making
You Crazy?
Disclosure
Speaker:
Kim Steele, RN, WCC, RAC-CT, CHHRP
Regional Consultant and Trainer
The speaker has no relevant financial
relationships to disclose
The speaker has no relevant nonfinancial
relationships to disclose

Program Objectives
The learner will be able to discuss the content of
S&C Memo 13-35-NH
The learner will be able to articulate the impact of
F309 and F329 on resident health and well-being
The learner will be able to list three risks of
antipsychotic use for the elderly
The learner will be able to identify the seven
Dementia Care Principles
The learner will be able to list three non-
pharmacological interventions for behavior
management

Is Antipsychotic Medication
Reduction Making You Crazy?

S&C Memo 13-35-NH
Released May 24, 2013
Conveys clarification to Appendices P
and PP related to nursing home
residents and F309 (Quality of Care)
and F329 (Unnecessary Drugs)
Announces mandatory surveyor
trainings, which are available online at
http://surveyortraining.cms.hhs.gov

F309-Quality of Care (§483.25)
Each resident must receive and the facility
must provide the necessary care and
services to attain or maintain the highest
practicable physical, mental, and
psychosocial well-being, in accordance
with the comprehensive assessment and
plan of care

F309-Quality of Care (§483.25)
Intent:
The facility must ensure that the resident
obtains optimal improvement or does
not deteriorate within the limits of a
resident’s right to refuse treatment,
and within the limits of recognized
pathology and the normal aging
process

F329-Unnecessary Drugs (§483.25)
Antipsychotic Drugs—Based on a
comprehensive assessment of the resident,
the facility must ensure that (i)Residents
who have not used antipsychotic drugs are
not given these drugs unless antipsychotic
drug therapy is necessary to treat a specific
condition as diagnosed and documented in
the medical record; and

Antipsychotic drugs, (continued)
(ii)Residents who use antipsychotic drugs
receive gradual dose reductions, and
behavioral interventions, unless clinically
contraindicated, in an effort to discontinue
these drugs

Intent: Each resident’s entire
drug/medication regimen be managed and
monitored to reach the following goals:
The medication regimen helps promote or
maintain the resident’s highest practicable
mental, physical, and psychosocial well-being,
as identified by the resident and/or
representative(s) in collaboration with the
attending physician and facility staff;

Intent (Continued)
Each resident receives only those medications,
in doses and for the duration clinically
indicated to treat the resident’s assessed
condition(s);
Non-pharmacological interventions (such as
behavioral interventions) are considered and
used when indicated, instead of, or in addition
to, medication;

Intent (Continued)
Clinically significant adverse consequences are
minimized; and
The potential contribution of the medication
regimen to an unanticipated decline or newly
emerging or worsening symptom is recognized
and evaluated, and the regimen is modified
when appropriate

Partnership to Improve Dementia
Care in Nursing Homes
Launched March 29, 2012 (formerly known as
National Partnership to Improve Dementia
Care and Reduce Unnecessary Antipsychotic
Drug Use in Nursing Homes)
The goal of this partnership is to “optimize
the quality of life and function of residents in
America’s nursing homes by improving
approaches to meet the health, psychosocial
and behavioral health needs of all residents,
especially those with dementia”

Per CMS, “Individualized, person-
centered approaches may help reduce
potentially distressing or harmful
behaviors and promote improved
functional abilities and quality of life
for residents”

The CMS has joined with various
stakeholders to improve care in nursing
homes
Actions:
Surveyor training videos
Updated Appendix P
Updated Appendix PP

Three Surveyor Training Videos:
http://surveyortraining.cms.hhs.gov
Overview of dementia care and potential
approaches to addressing behavioral distress
Walks surveyors thorough portions of an annual
survey and focuses on the evaluation of a patient
with dementia
Revised interpretive guidance for F309 and F329
and how to determine severity for non-compliance
related to care of a patient with dementia (still
under development)

Updates to Appendix P:
Changes to the resident sampling process
for the traditional survey
Changes to QIS were included in the recent
10.1.3 release
This change is intended to ensure that the
survey sample includes an adequate
number or residents with dementia who
are receiving antipsychotic medication

Updates to Appendix PP:
A new section of interpretive guidance at
F309 related to the review of care and
services for a resident with dementia
Revisions to the antipsychotic medication
section of Table 1 at F329
New severity example at he end of the
interpretive guidance at F329

A checklist was created for surveyor use
This checklist can be used in either
traditional or QIS survey
The checklist is not part of the SOM, but
was included in 13-35-NH for providers
review

The Concern…
In the past, psychopharmacological
medications have been used without first
determining whether there is a medical,
physical, functional, psychological,
emotional, psychiatric, social or
environmental cause of the behaviors
Medication may be effective when they are
used appropriately to address significant,
specific underlying medical of psychiatric
causes, or new or worsening behavioral
symptoms

The Concern…
Medications may be ineffective and are
likely to cause harm if given without a
clinical indication
All interventions, including
medications, need to be monitored for
efficacy, risks, benefits and harm
CMS states that its concern is that NHs
may use medication as a “quick fix” for
behavioral health issues and concerns

The Risk…
Antipsychotic medication is frequently
prescribed for residents who have
behavioral or psychological symptoms
of dementia (BPSD)
The term BPSD is used to describe
behavior or other symptoms in
individuals with dementia that cannot
be attributed to a specific medical or
psychiatric cause

The Risk…
When antipsychotic medications are used
without an adequate rationale, or for the
purpose of limiting or controlling behavior
of an unidentified cause, there is little
change that they will be effective
These medications commonly cause
complications such as movement
disorders, falls, hip fractures, CVAs, TIAs,
and increased risk of death

The Risk…
The Food & Drug Administration
(FDA) Black Box Warning Regarding
Atypical Antipsychotics in Dementia
reads: “Elderly patients with dementia-
related psychosis treated with atypical
antipsychotic drugs are at an increased
risk for death compared to placebo”

Resident’s Rights…
Informed Decision-Making: Residents
have the right to be informed about the
risks and benefits of any medication
Right to Refuse: Residents have the
right to refuse any medication
Freedom from Chemical Restraints: It
is against the law to give medications
that do not benefit the resident, such as
for convenience of staff

Fundamental principles of care for a
resident with dementia include an
interdisciplinary approach that focuses
on the needs of the resident as well as
the needs of other residents in the
nursing home
The revised CMS guidance and
surveyor training highlight and re-
emphasize these principles

1. Person-Centered Care
CMS requires nursing homes to
provide a supportive environment that
promotes comfort and recognizes
individual needs and preferences

2. Quality and Quantity of Staff
The nursing home must provide staff,
both in terms of quantity (direct care as
well as supervisory staff) and quality to
meet the needs of the residents as
determined by resident assessments
and individual plans of care

3. Thorough Evaluation of New or Worsening
Behaviors
Residents who exhibit new or worsening
symptoms should have an evaluation by the
interdisciplinary team, including the
physician, in order to identify and address
treatable medical, physical, emotional,
psychiatric, psychological, functional, social,
and environmental factors that may be
contributing to behaviors

4. Individualized Approaches to Care
Utilizing a consistent process that focuses
on a resident’s individual needs and tries
to understand behavior as a form of
communication may help to reduce
behavioral expressions of distress in some
residents
Individualized approaches are the first
line intervention for BPSD in the US, UK,
and Canada

5. Critical Thinking Related to
Antipsychotic Drug Use
Some residents will benefit from the use
of antipsychotic medication
The resident should only be given the
medication if clinically indicated and as
necessary to treat a specific condition
and target symptoms as diagnosed and
documented in the medical record

5. Critical Thinking Related to Antipsychotic
Drug Use
Residents who use antipsychotic drugs
must receive gradual dose reductions and
behavioral interventions, unless clinically
contraindicated, in an effort to discontinue
these drugs
Surveyors are instructed to review F222
(Right to be Free from Chemical Restraints)

6. Interviews with Prescribers
Surveyors are instructed to evaluate the process
of care, not evaluate the practice of medicine
Surveyors interview the attending physician or
other primary care provider (NP, PA),
behavioral health specialist, pharmacist, and
other team members to better understand the
reasons for using a psychopharmacological
agent or any other intervention for a specific
resident

7. Engagement of Resident and/or
Representative in Decision-Making
Residents (to the extent possible) and/or
family or resident representatives must be
involved in the discussion of potential
approaches to address behavioral
symptoms
These discussions with the resident and/or
family or representative should be
documented in the medical record

Antipsychotic Meds and Quality
Measures

Antipsychotic Meds and Quality
Measures
Antipsychotic med use affects two
Quality Measures
One long-stay and one-short stay
Percent of Residents Who Newly Received
an Antipsychotic Medication (short)
Percent of Residents Who Received an
Antipsychotic Medication (long)

Purpose of the Quality Measures
According to the CMS, Quality Measures
(QMs) have four purposes for consumers:
To give you information about the quality
of care at nursing homes in order to help
you choose a nursing home for yourself or
others;
To give you information about the care at
nursing homes where you or your family
members already live;

Purpose of the Quality Measures
According to the CMS, Quality
Measures (QMs) have four purposes for
consumers (Continued):
To give you information to facilitate your
discussions with the nursing home staff
regarding the quality of care; and
To give data to the nursing home to help
them in their quality improvement efforts

Quality Measures:
The Basic Calculation
QMs begin as a simple fraction (or ratio):
Numerator: all residents that trigger
Denominator: all residents of the facility
minus exclusions
Risk adjustment then refines raw QM scores
to better reflect the status of residents in the
facility
Most measures use at least one exclusion
The prevalence of an outcome after exclusions
is the facility-level observed score

an Antipsychotic Medication (Short-Stay)
Numerator: Short-stay residents for whom one
or more assessments in a look-back scan
indicates antipsychotic medication was received
Denominator: All short-stay residents who do
not have exclusions and who meet all of the
following conditions:
Has a target assessment
Has a initial assessment
Target and initial assessment are not the same
assessment

Exclusions:
Incomplete / missing data
Diagnosis coded on the MDS:
Schizophrenia
Tourette’s Syndrome
Huntington’s Disease

Clinical Considerations:
Non-pharmacological approaches to
behavior management and appropriate
GDRs
Antipsychotic medications carry a number
of risks for use in the elderly
Individualized behavior plans
Pharmacy reviews and Psych evaluations
Assess cognition and “play up” strengths

Antipsychotic Medication (Long-Stay)
Numerator: Long-stay residents
with a target assessment that
indicates an antipsychotic
medication was received
Denominator: All long-stay
residents who do not have
exclusions

Exclusions:
Incomplete / missing data
Any of the following diagnoses coded
on the MDS:
Schizophrenia
Tourette’s Syndrome
Huntington’s Disease

Clinical Considerations:
Non-pharmacological approaches to
behavior management and appropriate
GDRs
Antipsychotic medications carry a number
of risks for use in the elderly
Individualized behavior plans
Pharmacy reviews and Psych evaluations
Assess cognition and “play up” strengths

Clinical Considerations
Use of antipsychotics should be at t he
recommendation of the Interdisciplinary
Team, a Mental Health Professional or MD
All patients who receive an antipsychotic
should have routine screening for extra
pyramidal effects. This screen should be
initiated within 72 hours of starting
edication to establish a baseline.

Clinical Considerations
Notify the appropriate medical personnel
of any changes
When the Interdisciplinary Team feels it
would be inappropriate from a clinical
standpoint to attempt a GDR, consider
completing a risk vs. benefit analysis that
the team, MD and patient or family
reviews and signs

Documentation Requirements
Determine appropriateness of a
Gradual Dose Reduction (GDR) and
document that decision in detail.
Current regulation requires ongoing monitoring
for adverse consequence and GDR when clinically
appropriate.
Patients receiving any psychoactive medication
must have the positive effect and/or potential
adverse consequence monitored routinely by the
Interdisciplinary Team

Documentation Requirements
This monitoring should be documented
and reviewed by the attending MD on a
regular basis who will then make a
decision regarding the clinical
appropriateness of a GDR and document
that decision in detail
Ensure that the Pharmacy Consultant is
involved in this process and makes
recommendations as indicated

Monitoring
Clinically appropriate
Time frames
All disciplines responsible
Expected by DOH
Rationale for monitoring
Best way to track adverse consequence
Assists with clinical support for attempting
or not attempting GDR
Assist with care planning

Monitoring
Multiple tools available
AIMS
Facial and oral movements
Extremity movement
Global judgment
Dental Status
EPSE –Extra Pyramidal Side Effect
Tool

Monitoring
Facility specific tool – things to
consider
Tremors
Blink rate
Weight fluctuation
Change in sleep pattern
Change in behaviors

Developing the Plan of Care
Develop non-medication interventions
from all disciplines
Be creative in developing new
interventions if some don’t work
Some conditions will require immediate
medication intervention
When the Team determines it is
clinically appropriate to do so,
medication therapy will be initiated

Developing the Plan of Care
KEY POINT: The use of any
psychoactive medication will require
the Care Plan Team to develop a
detailed and patient specific care plan
addressing the behavioral symptom
that the medication is being given for

Developing the Care Plan
Some patients will continue to have
behaviors that are not relieved with
non-pharmacological interventions
Once the decision to use antipsychotic
medication is made it is critical to address
the use of the antipsychotic medication in
the existing care plan
Include how the patient will be monitored
for both positive effects and adverse
consequences

12 Questions to Consider
During Interdisciplinary Team
Review

Question 1
If the behavioral symptoms represent a
change or worsening, was a medical
work-up performed to rule out
underlying medical or physical causes
of the behaviors, if appropriate?

Question 2
Were current medications considered as
potential causes of the behaviors (i.e.,
those with significant anticholinergic or
other side effects?)

Question 3
If a medical cause (e.g., UTI) was
identified, was treatment (if indicated)
initiated in a timely manner?

Question 4
If medical causes were ruled out, did the
staff attempt to establish the root causes of
the behaviors, using a careful and
systematic process and individualized
knowledge about the resident when
possible? Were family caregivers or others
who knew the resident prior to his/her
dementia consulted about prior life
patterns, responses to stress, etc?

Question 5
Was the clinical indication for the
medication valid?

Question 6
Were non-pharmacologic, person-
centered intervention tried before
medications (other than emergency)?
Were the results documented?

Question 7
Were specific target behaviors
identified and desired outcomes related
to those behaviors documented? Were
caregivers aware of the target behaviors
and desired results of the medication?

Question 8
Was the resident or appropriate legal
representative consulted about the
decision to use an antipsychotic
medication and was that discussion
documented?

Question 9
If the drug is continued for more than a
few weeks, is the original clinical
indication still valid (are the behaviors
still present)?

Question 10
Is appropriate monitoring in place and
is the team aware of the potential side
effects?

Question 11
If new symptoms or changes in
condition occurred after an
antipsychotic medication was started,
was medication use considered as a
potential cause of a change or
symptom?

Question 12
If on a medication, did the pharmacist
perform a medication regimen review
and identify related signs and
symptoms, or did the staff inform the
pharmacist if symptoms occurred after
the last pharmacist visit?

Provider Self-Assessment Tool
Appropriate dementia care includes
more than managing individuals with
dementia-related behavior
Facilities must manage various factors
while also optimizing function in
medically complex patients
Facility systems are key in antipsychotic
medication management

See handouts:
Partnership to Improve Dementia Care in
Nursing Homes State Coalition Provider
Question Worksheet (Self-Assessment
Tool)
Partnership to Improve Dementia Care in
Nursing Homes Provider Implementation
Flow Diagram

Explore staff’s reaction to behavioral
responses by persons with dementia in
your facility
Determine if residents and families
given information about care options
for persons with dementia, including
those that do or do not use medications

How will your facility measure success
in improving dementia care and
reducing or optimizing antipsychotic
drug use?
Involve medical director, pharmacist
Staff education about behavior
management and facility policy and
procedure for behavior management

Section S (State Specific)
Section S is an optional section of the
MDS 3.0 assessment
Each state can choose if they wish to
include Section S
Each state can also determine what
items they wish to include in Section S
Massachusetts recently added
antipsychotic reduction questions

Section S (state specific)
Massachusetts Section S:
Determines if the resident has received and
antipsychotic
Determines if a dose reduction was done
Determines if the dose reduction was
maintained
Determines if non-pharmacological
resident centered care techniques were
utilized

Final Thoughts
Unnecessary use of antipsychotic
medications can have serious side
effects for the elderly population
Individualized, person-centered
approach to manage behavioral
symptoms is key
Holistic, interdisciplinary approach to
behavioral symptom management

References
Survey & Certification Memo 13-35-NH
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-
States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html
Quality Measures Users Manual
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-
Instruments/NursingHomeQualityInits/NHQIQualityMeasures.
html

References
Advancing Excellence in America’s
Nursing Homes
http://www.nhqualitycampaign.org/star_index.aspx?controls=d
ementiaCare
Circular letter DHCQ 13-9-597 (state of
Massachusetts)

Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
KSteele@harmony-healthcare.com
www.harmony-healthcare.com
Harmony Healthcare International, Inc. 81Copyright © 2013 All Rights Reserved 81Harmony Healthcare International, Inc.

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